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HEALTH INSURANCE (1997-99 GENERAL MEDICAL SERVICES TABLE) REGULATIONS 1997NO. 298
EXPLANATORY STATEMENTSTATUTORY RULES 1997 No. 298
Issued by authority of the Minister for Health and Family Services
Health Insurance Act 1973
Health Insurance (1997-99 General Medical Services Table) Regulations
The Health Insurance Act 1973 ("the Act") in part provides for payments by way of Medicare benefits, payments for hospital services and payments for matters concerning, related committees and tribunals.
Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.
Section 4 of the Act provides that the Regulations may prescribe a table of medical services (the table), other than diagnostic imaging services and pathology services, that sets out (a) items of medical services (b) the amount of fees applicable in respect of each item and (c) rules for interpretation of the table. The Health Insurance (1996-1997 General Medical Services Table) Regulations currently prescribe such a table, Section 4 of the Act also provides that, if not sooner repealed, these proposed Regulations cease to have effect on the day after the 15th sitting day after the end of the 12 month period commencing from the date of gazettal.
Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for general medical services set out in the table.
The purpose of the Regulations is to prescribe a new table of general medical services and rules of interpretation which incorporate the introduction of new services (e.g. Items 60 land 602 covering attendances by general practitioners between 11pm and 7am), the deletion of obsolete services and the amendment to the descriptions and/or fees of other services as a result of reviews of items in the table, and take account of a general increase in Medicare Schedule fees for 1997-98. The Regulations also provide for the repeal of the 1996-1997 General Medical Services Table. Further details of the Regulations are set out in the Attachment.
The Regulations came into effect on 1 November 1997.
ATTACHMENT
DETAILS OF THE CHANGES TO THE HEALTH INSURANCE (1997-1999 GENERAL MEDICAL SERVICES TABLE) REGULATIONS
Regulation 2 provides for the proposed regulations to commence on 1 November 1997.
Regulation 3 provides for the repeal of the 1996-1997 General Medical Services Table.
Regulation 4 prescribes the new table of general medical services and rules of interpretation.
Rules of Interpretation
Amended rules have been introduced for the purpose of interpreting the table. These are as follow:
(a) The item range in Rule 1 sub-rule (3) has been amended to reflect the deletion of item 61503 from the table. The item. range now reads 55028 to 61499.
(b) The item range in Rule 4 has been amended to take into account the new items relating to after hours visits in unsociable hours (that is, attendances conducted between the hours of 11:00pm and 7:00am each day).
(c) The item range in Rule 7 has been amended to take into account the items relating to home visits which are now calculated in the same manner as applied to attendances at hospitals, nursing homes and institutions.
(d) Rule 9 has been deleted as a consequence of the introduction of new item 10930, which has, necessitated the renumbering of subsequent rules.
(c) Item number 10816 has been added to Rule 9 sub-rule (2) and Rule 10 sub-rule (2) as this procedure replaces item 10815. Items 13604, 15600 and 16003 have also been included as these services require personal attendance by a medical practitioner.
(d) Rule, 11 sub-rule (2) has been amended to reflect the introduction of item numbers 11222, 11225 and 12207 and the deletion of item numbers 11227 and 12206.
(g) Rule 13 has been amended to include the item range 51700 to 53460. The range has been extended to include the three new oral and maxillofacial items that were added to the table in May 1997.
(h) Rule 14 has been amended to include item 18119 which has been introduced to the table to cover services relating to prolonged anaesthetics in connection with a dental service.
(i) The values in Rule 16 sub-rule (b) have been increased to reflect the effect of the general fee increase of 1.7 per cent.
(j) The values in Rule 17 sub-rule (b) have been increased to reflect the effect of the general fee increase of 1.7 per cent.
(k) The item range in Rule 22 has been amended to include item 12207 which was previously a Ministerial Determination and has now been included in the regulations.
(1) The item range in Rule 31 sub-rule (1) has been amended to include item 51318 which covers the procedures of assistance by a medical practitioner during cataract or intraocular lens surgery.
(m) The value in Rule 35 sub-rule (b) has been increased to reflect the effect of the general fee increase of 1.7 per cent.
(n) A new Rule (42) has been introduced to provide for the calculation of a fee for a cardiopulmonary bypass involving perfusion that exceeds 6 hours. The fee is calculated by using the fee for item 13603 plus 514.20 for each additional 10 minutes or part thereof that extends beyond 6 hours.
(o) A new Rule (43) has been introduced to provide for the calculation of fees for items
17800, 17805 and 17810. These items have been introduced to cover prolonged anaesthetic services. The fees are calculated using a value of $14.20 for each assigned anaesthetic time unit beyond the allocated time units if the procedure exceeds the base time by a specified time period.
(p) A new Rule (44) has been introduced to provide for the calculation of fees for anaesthetic procedures that have had to be discontinued prior to completion of the surgical procedure. The fee is calculated at the rate of 50 per cent of the appropriate fee had the procedure not been discontinued.
(q) A new Rule (45) has been introduced to provide for the calculation of fees for surgical procedures that have had to be discontinued prior to completion. The fee is calculated at the rate of 50 per cent of the appropriate fee had the procedure not been discontinued.
The remaining rules are unchanged.
TABLE OF SERVICES AND FEES
Budget related Amendments
(a) Schedule fees for all item other than attendance items in Groups A1, A2, A6 and A7 have all been increased by 1.7 per cent. The fees for items in Group A1 (general practitioner attendances) increased by .85 per cent with no fee increases for Group A2 (other unreferred attendances), Group A6 (group therapy) and Group A7 (acupuncture).
(b) Medicare outlays for optometrical services has been targeted as a high growth area and the structure of items relating to attendances by optometrists have been reviewed. Fees for a second comprehensive consultation by another optometrist within 24 months of an initial consultation are now set at the level of 50 per cent of the initial consultation rate. Allowance has been make for optometrists to refer patients to other optometrist if they are unable to provide the necessary service. The threshold for the provision of contact lenses has also been increased from 4 to 5 dioptres.
(c) Home visits by non specialists have been amended to cover the circumstances where a practitioner sees more than 1 patient at the same location. Previously, the loading for a home visit covered the extra costs of visiting patients away from the surgery was paid at the same rate for each patient seen. The new structure excludes any additional loading for second or subsequent patients.
Medicare Benefits Consultative Committee initiated changes
Other changes incorporated in the table result from reviews facilitated through the Medicare Benefits Consultative Committee, These changes involve the introduction of new services, the deletion of obsolete services and amendment to the descriptions and/or fees of other services. The changes are designed to ensure that the table reflects current medical practice. Details are as follow:
(a) LONG-TERM PSYCHIATRIC TREATMENT - The Government had given an undertaking to the Royal Australian and New Zealand College of Psychiatrists that the coverage of Item 319 would be reviewed upon the receipt of scientific evidence to support the efficacy of intensive long term psychiatric treatment of particular mental illness. Within the MBCC process and based on the advice of the Commonwealth Director of Mental Health, the department has agreed to a limited widening of the scope of item 319. Item 319 no longer refers to patients having a history of severe or physical abuse. It now covers persons diagnosed with personality disorders or a pervasive development disorder. The level of functional impairment now only applies to persons 18 years and over and the requirement that patients have a failed related psychiatric treatment has been removed.
(b) EXCISION OF SKIN LESIONS - The range of item descriptors covering excision of skin lesions have had fee levels adjusted to reign in overspending resulting from the 1 November 1996 amendments. The previous fee levels were set on advice from the profession relating to expected utilisation based on previous claim experience.
The new fee levels are based on the same relativities provided by the profession in 1996.
(c) UROLOGICAL SURGERY - The review arose from a submission by the Australian and New Zealand Association of Urological Surgeons. The Society's submission was discussed at a meeting of the MBCC held on 7 February 1997. It was agreed to add a new item to cover endoscopic pyelotorny and a revised structure to allow for an accurate itemisation of radical prostatectomy procedures.
(d) PERFUSION SERVICES - The review arose from representations by the Australian Society of Anaesthetists, the National Association of Medical Perfusionists of Australia and the Australian Medical Association. Benefits will now be payable for antegrade cardioplegia under the appropriate cardioplegia item, with the service being partly funded by a fee reduction for whole body perfusion. Increased benefits are now also payable for prolonged cardiopulmonary by-pass.
(e) OTHER MINOR AMENDMENTS - in order to improve the presentation of item descriptors, correct spelling, printing and proof errors and to better define certain items a number of minor amendments have also been made.